In the post below, “Can Empathy Be Taught?” Dr. Chris Johnson reflects on how and why, so many medical students seem to lose that compassion for others that is “innate in all of us,” and causes many students to choose the profession in the first place. Johnson writes: “We need to prevent medical training from driving [compassion] into the background, belittling it, or even snuffing it out.”
For nearly thirty years Johnson has been practicing medicine in an area that makes great demands on both the heart and the mind—pediatric critical care. It is a field that, in the words of 19th century medical ethicist Thomas Percival requires that the physician “unite” great “tenderness with steadiness.” Johnson is a blogger and the author of How Your Child Heals, How to Talk to Your Child’s Doctor, and Your Critically Ill Child.
Throughout most of his career, he has taught medical students, residents, and fellows. “I also served on a medical school admissions committee for some years,” he notes “and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system got hold of them.”
Before reading Johnson’s post, you should know what inspired it.
A few months ago, I sent him a riveting essay that I had just read in the New England Journal of Medicine, and asked if he would like to write a guest post about it. The “Perspective,” titled “Into the Water—The Clinical Clerkships” was co-authored by a third-year medical student at Harvard, Neal Chatterjee, and Dr. Katharine Treadway, who teaches at Harvard and practices at Mass General. Together, they describe how medical students learn to distance themselves from the sights and sounds that surround them when they move from the classroom to the hospital in their third year of training. “It is ironic that precisely when students can finally begin doing the work they believe they came to medical school to do — taking care of patients — they begin to lose empathy,” Treadway notes. “Studies have documented the high level of compassion with which students enter medical school and the sharp decline that occurs during the ensuing 4 years. . . Most of the decline occurs in the third year.”
Initially, most third-year students are overwhelmed by what they see and hear—the human condition laid bare. Patients die. Others suffer, and cry out. Some must be tied to their beds. Human flesh is “filleted,” on an operating table.
At the end of his third year, Chatterjee describes what he witnessed:
“I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently' because I was at home, sleeping under my own covers, when she coded.
“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips.
“I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.
“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.' I have said nothing about that incident.
“I have delivered a baby. Alone. I have sawed off a man's leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night.
“I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”
Inevitably, third year medical students bear witness to more human suffering than many of us see in a lifetime. “As [students] have their first experiences with patients dying, they don't know how they should respond, whether it's OK to be upset,” Treadway observes. . . “Responses to these events are rarely discussed . . . most students enter medical school caring deeply, and we actually teach them not to care — not intentionally, but by neglect, by our silence.” A patient dies, and doctors leave the room, without comment. “We place them in profoundly disturbing circumstances and then offer no support or guidance about what to do with the feelings they have in abundance,” writes Treadway. This, she suggests, is “the hidden curriculum” (the transmission of the dominant culture) or the “professional socialization that alters the student's beliefs and value system so that a commitment to the well-being of others either withers or turns into something barely recognizable.”The impact of this hidden curriculum is profound.”
She quotes Renee Fox, a medical sociologist: “As they struggle, individually and collectively, to manage the primal feelings, the questions of meaning, and the emotional stress evoked by the human condition and uncertainty . . . medical students . . . develop certain ways of coping. They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor . . . They are rarely accompanied, guided, or instructed in these intimate matters of doctorhood by mature teachers and role models. Generally their relations with clinical faculty and attending physicians are too sporadic and remote for that.”
Ultimately, students become numb to much of what they see and hear. Or as Chaterjee puts it, “the extraordinary” begins to seem “mundane.” He suspects that this response is an inevitable consequence of medical training, “a survival mechanism.”
Inevitably, students take their cues from those around them. Chatterjee describes the first role model he encountered when he began his third year. “ I arrived…freshly shaven, nervous, absorbent — for the first day of my surgical clerkship. As I joined my team, my resident was describing a recent patient: “He arrived with a little twinge of abdominal pain . . . and he left with a CABG, cecectomy, and two chest tubes!” This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote — slouched in his chair, legs crossed and coffee in hand — seemed oddly . . . comfortable.”
In the months that followed, Chaterjee learned to blend in. He sums up his experience: “The third year of medical school is like being thrown head first into water. Although the impact is jarring, eventually the experience becomes natural. We become comfortable— legs-crossed, slouched-in-a-chair, coffee-in-hand kind of comfortable.
“Occasionally, however, were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time. These moments were often lost amidst morning vital signs, our next admission, or the differential diagnosis for chest pain. If we focus on them closely, we see that our lives are filled with these moments. The challenge is to collect them in a meaningful way — to spend time with them, wrestle with them, allow the discomfort they generate to sit inside us.”
Chatterjee did not want to lose his humanity. Eventually he learned to share those moments: “During my third year, I met with eight classmates for 2 hours every other week. What initially seemed an intrusion into our busy lives became an almost sacred space for recognition — both recognition that others felt similarly challenged, uncomfortable, and uncertain and recognition of moments that would otherwise have remained buried under Noon Conference attendance and potassium repletion. Most important was the shared nature of this collective self-examination, which helped buffer the inevitable discomfort and emotion that these moments generated. . .
“The shared reflection and consideration we engaged in empowered us . . . exploring some moments helped us to cherish their wonder and retain the humility they inspired, focusing on others helped us to strengthen our advocacy for patients.
“During my intern year, this reflective power has stayed with me. An experience that might otherwise seem to be an errant thread is now held carefully and closely — and eventually woven into the fabric of my training.”
After I read this essay, I looked at some of the research listed in the footnotes. In particular, I recommend “Vanquishing Virtue: The Impact of Medical Education” by Jack Coulehan. It is too long to discuss here, but I hope to write about it in another post.
Other research suggests that, at the beginning of medical school, as students become aware that medicine is fraught with ambiguity, they begin to change. The science it turns out is not as clear-cut or “scientific” as television suggested. Or put it this way: Medicine remains an evolving body of knowledge. Bright students begin to recognize that some of what they are being taught is probably “wrong.” In ten or fifteen years, research will topple more than a few of today’s theories and replace them with new ones.
But the real transformation comes when they begin to have contact with hospital patients. This is when idealism turns to cynicism directed against patients (particular poorer patients whose own "behaviors" have caused their illness), as well as cynicism about medicine itself—and “self-mockery”.
According to the studies about one-quarter of all med students escape this erosion of their capacity for empathy. Typically they are women who go into the "core" specialties where they see patients over a period of time—family medicine, pediatricians, ob-gyns, as opposed to proceduralists who often see a patient only for a single episode of care. (See “Is There a Hardening of the Heart During Medical School?”)
In this context, I am suspicious of a number as precise as “27 percent,” but it makes sense such hardening of the heart is not inevitable. Researchers report that some medical students are, for a variety of reasons “immunized” against the hidden curriculum and remain extraordinarily empathetic. I would add that I know radiologists and oncologists whose imaginative and affective capacities have not atrophied. And I have met female primary care doctors who were wholly lacking in compassion.
As the “modern medicine” of the 20th century developed, doctors were counseled that they needed to detach themselves from their patients in order to defend themselves; otherwise they wouldn't survive. Today, those who study doctors suggest that the combination of hard-boiled cynicism and “medical humor” that Chatterjee’s resident exhibited itself causes burn-out.
When I sent “Into the Water” to Chris Johnson I asked him some questions: “Can compassion and empathy be taught? Can it be taught by older doctors serving as models? Does this mean that older physicians should allow their emotions to show on their faces when they are distressed by a patient's suffering?”
Below his response.